2.01 Periorbital Ecchymosis (Black Eye)

Presentation

The patient has received blunt trauma to the eye, most often from
a fist, a fall, or a car accident, and is alarmed because of the swelling and
discoloration. Family or friends may be more concerned than the patient
about the appearance of the eye. There may be an associated subconjunctival
hemorrhage, but the remainder of the eye exam should be negative and there
should be no palpable bony deformities, diplopia or subcutaneous emphysema.

What to do:

Clarify as well as possible the specific mechanism of injury. A fist is
much less likely to cause serious injury than a baseball bat.

Perform a complete eye exam including a bright light exam to rule out an
early hyphema, a funduscopic exam to rule out a retinal detachment or
dislocated lens, and a fluorescein stain to rule out a corneal abrasion.
Visual acuity testing should always be performed, and with an uncomplicated
injury, would be expected to be normal. All patients having contusions
associated with visual loss should be referred to an ophthalmologist.
Special attention should be given to ruling out a blowout fracture of the
orbital floor or wall. Test extraocular eye movements, look especially for
diplopia on upward gaze, and check sensation over the infraorbital nerve
distribution. Enophthalmus is usually not observed, although it is part
of the classic textbook triad associated with a blow-out fracture. Sub-
cutaneous emphysema is a recognized complication of orbital wall fracture.

Symmetrically palpate the supra- and infraorbital rims as well as the
zygoma, feeling for a deformity such as one would encounter with a displaced
tripod fracture. A unilateral deformity will be obvious if your thumbs are
fixed in a midline position while you use your index fingers to palpate the
patient's facial bones simultaneously both left and right.

When there is a substantial mechanism of injury or if there is any clinical
suspicion of an underlying fracture, obtain x rays of the orbit. CT scans
are more sensitive and can visualize subtle fractures of the orbit and small
amounts of orbital air. CT scanning is indicated for patients with abnormal
physical examinations but normal routine films.

If a significant injury is discovered, then consult with an ophthalmologist.

When a significant injury has been ruled out, reassure the patient that the
swelling will subside within 12-24 hrs with use of a cold pack and the
discoloration will take one to two weeks to clear. Acetaminophen should be
all that is required for analgesia.

Instruct the patient to follow up with an ophthalmologist if there is any
problem with vision or pain developing after the first few days. Uncommonly,
traumatic iritis, retinal tears, or vitreous hemorrhage may develop later
secondary to blunt injury.

What not to do:

Do not get unnecessary radiographs. Minor injuries with normal eye exams
and no palpable deformities do not require x rays.

Do not brush off bilateral deep periorbital ecchymoses ("raccoon eyes")
especially if caused by head trauma remote to the eye. This may be the only
sign of a basilar skull fracture.

Discussion

Black eyes are most commonly nothing more than uncomplicated facial
contusions. Patients become upset about them because they are so "near the eye,"
because they produce such noticeable facial disfigurement, and because there is
often secondary gain being sought against the person who hit them. Nonetheless,
serious injury must always be considered and ruled out prior to the patient's
discharge from your care.